How Can Tranexamic Acid Help in EMS?

While EMS use of tourniquets and hemostatic dressings have proven effective at increasing survival from trauma, some forms of traumatic hemorrhage shock continue to prove decidedly deadly. Brisk internal hemorrhage from penetrating and blunt trauma can’t always be easily addressed with these solutions. But an old chemical might just make a difference.

That chemical is tranexamic acid (TXA). It won’t replace the ongoing importance of timely, organized on-scene trauma care, in conjunction with rapid, safe transport to an appropriate trauma care destination, but two recent landmark studies are cause for great optimism.

Both studies clearly center on the use of TXA for traumatic hemorrhagic shock. TXA is classified as an “anti-fibrinolytic,” or a clot stabilizer. You can think of it as working in the opposite direction from how thrombolytics work for myocardial infarctions or strokes. Although TXA has existed for decades—being used in cardiovascular surgery, treatment of hemophilia and treatment of difficult uterine bleeding—it is still relatively new in the approach to hemodynamic instability from trauma.

The Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage 2 (CRASH-2) study is the larger of the two studies that deserve our attention. CRASH-2 involved over 20,000 patients across multiple countries—though not the United States. The end result was that in the setting of trauma with significant bleeding—or at great risk for serious bleeding—with tachycardia and hypotension, patients who received TXA had a mortality of 14.5%. Compared to a mortality of 16.0% among those who received a placebo, this proved a statistically significant benefit to receiving TXA. Importantly, when considering a medication that stabilizes clotting—perhaps even promoting it—there were no statistically significant increases in clot complications, such as myocardial infarctions, strokes, pulmonary embolisms or deep venous thromboses. This is an important study and can be read directly at the CRASH-2 website, www.crash2.lshtm.ac.uk.

The smaller of the two studies—but equally important for consideration in EMS—is the Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. This study involved TXA administration in an out-of-hospital setting, on British military medevac helicopters in Afghanistan. Patients were included in this study if hemorrhagic shock was suspected and they were transfused at least one unit of blood. Additional investigation was done in patients who required at least 10 units of blood for stabilization. As in CRASH-2, MATTERs revealed a statistically significant survival benefit when receiving TXA—17.4% in comparison to 23.9% mortality without TXA. MATTERs did cause a note of caution in that there were statistically significant increases in clotting complications of pulmonary embolisms and deep venous thromboses, yet the absolute numbers were quite small.

Both studies should be read thoroughly and EMS medical directors and local trauma specialists must be involved in the considerations of whether TXA is appropriate for the local standard of EMS care.

At present, the cost of TXA in the 1 gram dose that EMS would administer over a 10 minute IV piggyback infusion is approximately $55. It’s clearly not free, but considering its impact it’s quite cost effective when considering the increased survival rate in the most serious of trauma cases.

In metropolitan Oklahoma City and Tulsa, physician medical oversight is provided by the Medical Control Board (MCB) and its Office of the Medical Director. With support from trauma surgeons in both Oklahoma City and Tulsa, the MCB unanimously approved TXA for EMS use on January 16, 2013 with implementation on April 1. Key to ensuring the right patients receive TXA and the wrong ones don’t, a detailed continuing education review of both landmark studies and how TXA is to be used in the local standards of care was created. The program features the system’s medical director and Oklahoma City’s massive transfusion in trauma expert, Dr. Will Havron. Paramedics are required to receive this education and complete real-time patient screening checklists prior to TXA administration. As you can imagine, we’re watching these patients closely in CQI formats and look forward to sharing our impressions over the next several months. We’ll watch these patients and their outcomes carefully and report back.

Patient Eligibility Check Lists

Metropolitan Oklahoma City TXA Criteria

• Adult patient 18 years of age or older
• Hemorrhagic shock due to trauma
• Trauma less than 3 hours old
• Patient has received 1 liter of NS
• Sustained tachycardia 120 bpm or greater
• Sustained hypotension systolic 90 mmHg or less
• Patient is being transported to OU Medical Center Presbyterian Tower
• Transport time 15+ minutes to OU Medical Center Presbyterian Tower

Metropolitan Tulsa TXA Criteria

• Adult patient 18 years of age or older
• Hemorrhagic shock due to trauma
• Trauma less than 3 hours old
• Sustained tachycardia 110 bpm or greater
• Sustained hypotension systolic 90 mmHg or less
• Patient is being transported to Saint Francis Health System or St. John Medical Center

Bibliography

1. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg, 2012 Feb; 147(2): 113—9.

2. Shakur H, Roberts I, Bautista R, Caballero J, Coats T, Dewan Y, El-Sayed H, Gogichaishvili T, Gupta S, Herrera J, Hunt B, Iribhobge P, Izurieta M, Khamis H, Komolate E, Marrero MA, Mejia-Mantilla J, Miranda J, Morales C, Olaomi O, Olidashi F, Perel P, Peto R, Ramana PV, Ravi RR, Yutthakasemsunt S. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet, 2010 Jul 3; 376(9734): 23–32.

Jeffrey M. Goodloe, MD, NREMT-P, FACEP, is professor and chief of the EMS Section of the Department of Emergency Medicine at The University of Oklahoma School of Community Medicine in Tulsa. He serves as medical director for the Medical Control Board, providing physician oversight for the EMS System for Metropolitan Oklahoma City and Tulsa, working with a multitude of agencies, including the Emergency Medical Services Authority (EMSA), the Oklahoma City Fire Department and the Tulsa Fire Department. He began his career in EMS in 1988 as an EMT-Basic. Contact him at jeffrey-goodloe@ouhsc.edu.

David S. Howerton, NREMT-P, is director of clinical affairs-western division for the Office of the Medical Director in Oklahoma City and Tulsa. He’s the medical oversight liaison for all metropolitan Oklahoma City agencies working with the Medical Control Board. His EMS career spans nearly three decades and includes a multitude of clinical and administrative leadership roles. Contact him at howertond@emsa.net.

Duffy McAnallen, NREMT-P, is director of clinical affairs-eastern division for the Office of the Medical Director in Oklahoma City and Tulsa. He’s the medical oversight liaison for all metropolitan Tulsa agencies working with the Medical Control Board. His EMS career spans over three decades and includes a multitude of clinical and administrative leadership roles in EMS, fire and law enforcement. Contact him at mcanallen@emsa.net.

Howard Reed, NREMT-P, is director of research and clinical standards development for the Office of the Medical Director in Oklahoma City and Tulsa. His EMS career spans nearly three decades and includes a multitude of clinical and administrative leadership roles. Contact him at reedh@emsa.net.